Introduction to Psychiatric NursingModule 2: Concepts

RNSG 2213

History Concepts

How were mentally ill treated prior to1790’s? Banishment Confinement

What were attitudes toward them? Possessed by the devil Lacked basic human qualities

St. Mary of Bethlehem Hospital, London (“Bedlam”) Opened to lunatics 1403

Visitors pay for “entertainment”

History Concepts

Period of Enlightenment begins in 1790’s Concept of “ Asylum” (sanctuary):

If we treat patients humanely and

respectfully, they will improve. Mental illness worsens with stress

First mental hospitals (“asylums”) in US in 1820’s

History Concepts

Who was Dorthea Dix? A nurse who was one of the first major

reformers in the United States. Helped develop the concept of an asylum Direct role in opening 32 state hospitals

Dorthea Dix Asylum in North Carolina

Austin, Texas State Insane Asylum 1851

Era of Psychotropic Drugs

Medications first available in 1950s, i.e. chlorpromazine (Thorazine) for Schizophrenia, Lithium for Mania

Hope for previously “incurable” mental illnesses and enhanced quality of life.

Community Mental Health Movement Response to the overcrowding and bureaucracy of public

mental hospitals. Chronically mentally ill “warehoused” and often

abused, neglected 1963 Community Mental Health Act

Concept: Patients can be treated better, cheaper in community

Massive deinstitutionalization: All State Hospitals in some states closed

Results: Increased acuity and strain on emergency services, increased number of homeless mentally ill

ETHICAL ASPECTS: SOCIAL VALUES(Consider what effect each of these values has on mental health care) Individual Freedom Money Paternalism vs Libertarianism

Paternalism believes that an authority knows what is best for you

Libertarianism believes that the individual knows what is best for them

No other area of nursing is so affected by social values as psychiatric nursing

A Nurse Needs to Know About:

How to adapt legal principles to mental health settings: safeguarding nursing practice from charges of

negligence, false imprisonment, assault, or battery DUTY TO WARN

Mental health professionals must warn others of a client’s threat of suicide or of harm to self or others

Rights of Psychiatric/Mental Health Patients

Right to refuse treatment Right to informed consent ( and the right to

know about rights) Right to confidentiality Right to receive visitors and telephone

calls Right to be treated with respect Right to be treated in the least restrictive

environment

Client Rights

Concept of Least Restrictive Environment: Should guide nursing decisions Seclusion is used when the person is a danger to

others Restraint is used when the person is a danger to

self Never used to get a patient to comply

Rights of Mentally Ill Patients Basic Needs:

Warmth: clothing a blanket Food Access to the outdoors

Contact with family, legal representative Do NOT have right to all possessions

(When can access to possessions be restricted?)

Legal Aspects: Commitments

(As Applied under Texas Law) Mental illness as defined by the Texas Mental

Health Code “Mental illness is a disease or condition

which either: Substantially impairs the person’s thought,

perception of reality, emotional process and/or Grossly impairs behavior as manifested by a

recent event of disturbed behavior (“Gravely disabled”)

Commitments

Voluntary Commitment A person 16 years of age or over signs

themselves in for admission. Person is advised of their rights under the code.

4 Hour Rule: If a patient changes their mind about being in the hospital, psychiatrist has 4 hours to file for a commitment.

Signs a consent for treatment.

Commitments, cont’d

Most commitments are voluntary where the individual or the therapist request admission and the patient meets criteria for admission

The patient must sign consents for all psychotropic medications. Refusal to sign these consents means the medications can NOT be administered

Involuntary Commitments

Emergency Mental Illness Commitment Allows Mental Health Deputies (Crisis Intervention Team) to pick up a person who presents an “IMMINENT DANGER TO SELF OR OTHERS” and is “Gravely Disabled”

and bring them into custody for 24 HOURS. MD can begin commitment procedures (file)

at that time.

Involuntary Commitments, cont’dOrder of Protective Custody (OPC) Commitment must be accompanied by a

medical certificate, which states that the physician has examined the patient within 24 hours. Filed at the County Clerk’s Office.

Probable Cause Hearing within 72 hrs. Pt. can be committed for 14 days.

Involuntary Commitments, cont’dTemporary Commitment Papers must be filed with the Court Hearing before a judge with physician and patient

present. Must prove “Danger to self or others” or meets the

deterioration standard Can be committed UP TO 90 DAYS. May be discharged any time staff believes pt. is

ready. May change to Outpatient Commitment

Involuntary Commitments, cont’dExtended Mental Health Commitment

Very strong evidence needed Commitment is up to 1 year.

Last but not least . . . .

All involuntary commitments can include court-ordered medications

All commitments discussed previously can apply to Chemical Dependency

TREATMENT SETTINGS AND THE CONTINUUM OF CARE Where do we see the mentally ill being

treated? How do individuals enter the mental health

system? Why is discharge planning so important?

PSYCHOTHERAPEUTIC MANAGEMENT TOOLS ARE:

SELF DRUGS ENVIRONMENT

Therapeutic Use of SELF (Nurse-Client Relationship)

DRUGS: Psychopharmacology ENVIRONMENT: Therapeutic Milieu

NURSE ON THE MENTAL HEALTH TEAM Mental Health Team:

Psychiatrist Nursing staff: includes licensed nurse, tech Psychiatric Social Worker Psychologist Therapeutic Recreation and Expressive Arts

personnel Client and Family Other: Substance abuse counselor, employment

specialist, dietician, etc.